New TRICARE Change Could Force You to Stay with PRIME

By: MJ Boice, Staff Writer

“My Primary Care Manager (PCM) fought with me for two years, insisting I didn’t need the thyroid medication I had previously been prescribed” Army spouse Kristen, explained. Later, after being injured in a riding accident, Kristen faced more challenges with her PCM. “The ER brushed me off, my PCM insisted it was nothing and refused to refer me for an MRI.”

But after six weeks with no progress, Kristen decided to switch to TRICARE Standard (soon to be rebranded as TRICARE Select.)

“I called TRICARE at 9:00 a.m. on a Tuesday morning to switch to Standard, and 30 minutes later, I had an appointment with a specialist for my thyroid issues, as well as a same-day appointment for my knee and hand from the riding injury,” she said.

Only a few hours after switching from TRICARE Prime, Kristen’s new doctor evaluated her, did an x-ray, scheduled an MRI, and referred her to an orthopedist. Because she was able to switch to Standard, she got the right care, at the right time, and the right place.

But switching from Prime to Standard at the drop of a hat may not be that easy for long.

Currently, military families who have TRICARE Prime can switch to TRICARE Standard at any time, for any reason. This provides a critical escape hatch for military dependents, like Kristen, who feel they aren’t receiving adequate access and medical care at their Military Treatment Facilities (MTF).

But the National Defense Authorization Act (NDAA) mandates a TRICARE annual open enrollment period that could close the escape hatch and limit military family options for switching from Prime to Standard/Select.

With an annual open enrollment period, military families will have one specified period each year to select a TRICARE plan. Once you’ve made your selection, you are locked in for an entire year until the next open enrollment period.

The only way to get out of your selection would be a “qualifying life event” or QLE. The NDAA does not list specific QLEs and gives DoD some discretion in defining them. However, commercial plans typically define QLEs as changes in household (e.g., getting married or divorced, birth of a baby or adopting a child), relocation, or loss of health insurance. Without a QLE, you’re stuck with your TRICARE plan choice until the next open enrollment—even if the health care you’re receiving doesn’t pass the smell test.

Military families who decide to make the switch from TRICARE Prime to TRICARE Standard cite different reasons for doing so. For example, many military spouses choose to switch from Prime to Standard for prenatal care. However, depending on how the policy is written, pregnancy may not be considered a qualifying life event.

Navy spouse, Jenna, who has a history of ectopic pregnancies, didn’t want to risk it. Her previous doctors strongly urged her to be evaluated immediately with all future pregnancies. Jenna found out she was pregnant a week after her husband deployed.

“I called to get an appointment and was told I couldn’t be seen until I was 14 weeks, even with the risk of another ectopic pregnancy. The scheduler refused to give me an appointment,” she shared.

Jenna was told to go to the ER if she felt she was experiencing a miscarriage. After sharing this medical advice with her husband, both felt it was safest to switch to TRICARE Standard. She did, and was evaluated right away.

The reasons when and why military families switch from Prime to Standard vary based on the unique needs of each family member.

We’re concerned that an annual open enrollment period may effectively trap military families in the MTF, regardless of the problems they experience with access or quality of care.

“While there are many wonderful military health care providers, the system has conditioned us to accept substandard treatment when it happens to us,” said Kristen. “I'm done with it.” Kristen’s frustration comes from 18 months of after-effects from not receiving adequate or prompt care in her MTF.

We appreciate the opportunity given us by the Defense Health Agency (DHA) to provide military family feedback as they translate the NDAA legislation into TRICARE policy. Our Association is not opposed to an open enrollment period as long as families can keep the option of switching to Standard/Select if they are dissatisfied with their health care or patient experience at the MTF. We believe one potential solution is to include “dissatisfaction with MTF access or quality of care” as a qualifying life event. Not only would this allow families like yours to switch to civilian care if necessary, but it would also provide accountability within the MTFs.

We look forward to meeting with DHA to share military family feedback about how an annual open enrollment period could impact families like yours..

Your military family’s story will help shape TRICARE reform, so tell us: How do you feel about this policy change that would limit your options for switching from Prime to Standard? If you’ve already made the switch to Standard, how would this have affected your family?

Posted July 18, 2017

Comments

From: Kelly Buck on: August 5, 2017

My husband has been in the navy and then coastguard since 2000. I have had horrific experiences with base hospitals, base doctors, and tricare prime in general. I've had very few exceptions to this. A couple Dr. Here and there were exceptional. Since I live 45 minutes from either base with traffic and don't own a car, this is unacceptable. I have terminal Multiple Sclerosis, chronic bronchial asthma, allergies, colitis, IBS, kidney stones, abnormal apps occasionally getting biopsied for cervical cancer, eczema, high blood pressure forms stress, and a level 2 heart murmur, and a few minor medical issues. I have tricare prime because with the amount of Dr. I see, I can't afford the copays every appt. I get rides from friends or ride the handicapped bus to them. I had so many problems with very bad care, negligent and unknowledgeable Dr, and Dr, and staff that are just plain apathetic and uncaring. Not something I want to deal with in an ER on a base when I'm turning blue and passing out from bronchitis turning into pneumonia. My MS weakens my immune system n has allowed bronchitis to stick around in a diminished capacity n hide in my body all year long, travel to other parts in my body n not get killed off by antibiotics. And I'm allergic to several antibiotics. Once it snuck in my inner ear n killed the utricle in my right ear. Its 1 of the 3 inner ear pieces. All 3 control balance. The utricle is the 1 that controls spinning around balance. The other 2 control front-back, n side to side balances. I had to get physical therapy n medicine to correct my balance n nausea from it. Tricare cut off my physical therapy about halfway through. My furious therapist is used to that BS from tricare n devised a plan with me that I can MacGyver my way through at home. Good thing I'm an artist with a wide open imagination. With the garbage care I get from the military bases, I've had to get creative to find ways around their BS, and the lazy way people behave at being Dr n nurses in military hospitals. I got help from the tricare liaison, and stayed on her n tricare for 3 years, n getting recommendations from Dr, n specialists there at the military hospital to give me a civilian PCM who could refer me to other civilian specialists better suited to help me, n closer for me to get to, easier by bus. I went undiagnosed with symptoms for 7 or 8 years. Then I got referred to Dr Kalina Sanders neurology. She's a genius and a good investigator. She diagnosed me in 6 months. She moved to another hospital that doesn't take tricare prime. So she lost all her tricare prime patients that wanted to move with her. I'm still working on it. It's something she's working on changing. Tricare has denied me for an oxygen machine many times with numerous requests from 3 of my Dr. I got 1 from a local charity. They have also denied me several times for a home healthcare aid that I need badly. I'm on 2 different 2 year long state waiting lists for 1 through state programs. It's been 3 years. I keep getting bumped down the list by people maybe or maybe not worse off then me. My insurance is supposed to cover a home healthcare aid. And I cant get SSDI in this idiotic state without a lawyer n fighting 5 years for it. I've been denied 3 times in person, though I have loads of proof. They said come back when I'm in a wheelchair. Which is illegal. I'll be lucky If tricare pays for that wheelchair at all when I do need it.

From: Natalie on: July 26, 2017

Military families are forced to move at the drop of a hat, not on an annual basis. The healthcare situation varies dramatically depending on where you are stationed. This new policy is an unfair means of saving money and manpower, but will undoubtedly hurt military families. If I wasn't on standard, my daughter would have been born in a car with my precipitous labor, as the nearest base of delivery that I was assigned was 45 min away-at best-in DC traffic. But I didn't know this was the scenario until I had just moved.

From: Melanie on: July 20, 2017

I've had Tricare standard and prime, personally and for my three children, and I have to say, I agree with all the negative comments about Prime. My son had a collapsing trachea. It had been discovered before he was a year old. At age 3 the strider returned. The MTF DX it as "hiccups" I left the appointment, in disbelief, and walked straight to the enrollment office. I moved him from prime to standard and within 24 hours had a civilian children's specialist "waiting for me in the lobby" to do a scope on my son. Where the MTF dismissed a possible life threatening condition, the civilians treated it like it was their priority and moved mountains to get immediate answers. From that moment on, all three of my kids were standard. I don't think we should be punished for the incompetence of the staff at the MTF or pidgeon holed into a plan that doesn't offer access to the care we desperately need. I don't find it to be so expensive that I can't afford it, the caps are reasonable and everything my children have needed has been covered by Tricare standard. We've done OT, Behavioral therapy, and now dyslexia therapy. My youngest had his tonsils removed, and it was covered, 100%. Because our situations change and from one appointment to the next our PCMs can change, we should have flexible insurance to meet our unique situations, not whatever is available at the time. locking us into one or the other can cause undue stress for the service member, as well as the spouse and certainly should not be a concern to military members when they are trying to stay deployment ready. If we are forced to continue to use prime and not opt out, then we need better providers and more options so that we are not stuck fighting for better care and accurate diagnoses.

From: Raven on: July 20, 2017

If they want people to stick with prime then they need to provide better care on post. There's no reason a woman should have to wait 20 weeks to receive prenatal care and my son shouldn't have to wait 2 months for a well child check up. There should be more of an open policy when it comes to referrals to be seen by another doctor when facilities are at max capacity or when a person doesn't feel like they are getting adequate care.

From: Adria on: July 20, 2017

I question the necessity of policy changes that will make it more difficult for service member dependents to switch to Tricare Select (nee Standard). We have the right to seek out the care we feel is best for us; if we are expected to remain on TriCare Prime then improvements should be made to Prime to reduce the rate of divorce from the plan rather than making it harder to switch to Select.
In short, when medical facilities and staff prioritize regulation over care then beneficiaries will flee to find better service elsewhere. Improving the condition of the program is far less expensive in the long run than forcing people to stay on plans that are endangering their health.

From: Dianna on: July 19, 2017

For us Prime is the better choice. In the long run it saves money if you may have major surgery. However, yes, there are hoops to jump through. We pay extra to have prime verse standard. Where as standard has more out of pocket cost, which can be spendy. Expecially if you have surgery and/or end up in the hospital. I and my husband in the last year have had unexspect surgeries. With standard it would be in the thousands of dollars out of pocket. With prime,a few hundred. Read both policies and really have a idea of what works for your family.

From: Manda on: July 19, 2017

This change would make it almost impossible for my family to receive care in the town we live in stationed as recruiters two hours from the nearest MTF. There is one Pediatrician that accepts Prime and his acceptance of new patients is hit or miss. I would not be able to find an OB at all. Most of the PCMs that accept Tricare Prime in this city have waitlists and they ALL require you have an establish patient visit before they will see you for an illness. Even if you have one scheduled but it is weeks out. At which point you then have to improperly use an ER or use up the alloyed urgent care visits. Also, my step children come visit for long holidays off school and we wouldn't be able to rotate their PCMs as necessary.

From: Courtney on: July 19, 2017

If this is approved, and the 'open enrollment period' is the only time in which I would be allowed to switch to standard, I would feel I have no choice but to switch immediately to avoid being stuck in The tricare Prime plan. I have received exceptional care from military facilities, and I have also received severely sub-standard care, and extremely unsatisfactory treatment, some through the loss of a baby boy during pregnancy. Even after speaking with patient advocates, and the medical chief of staff, no changes were made, and the 'unacceptable care' that I received went unreprimanded. all of my OB care will be supervised by civilian providers of my choice in te future, and this choice should ALWAYS be mine to make, at any time. Providers and MTFs need to be held accountable for the treatment that they provide.

From: Amanda Meier on: July 19, 2017

I am currently on Standard while my 4 kids are on Prime. I switched to Standard for my 3rd pregnancy because I was not satisfied with quality of care for my obgyn needs (after having problems with care before getting pregnant) and wanted more control over such a major life event. I stayed on Standard because it was the better choice for me and my medical needs. I have certain minor medical issues that need monitored, but was denied appt with the specialist that my pcm was referring me to since to my lab work was within "normal" range. Without even seeing me or listening to my concerns the military specialist office denied my referral despite having been diagnosed with this for a few years and being on medication (while still experiencing problem symptoms).
The open enrollment will be problematic for patients like me who are desiring a certain standard of care because of more complex medical needs. They already limit the amount of times that we can switch between Prime and Standard. We have so little control over care through an MTF that it seems like this is adding more limited medical decisions for military families. We deserve to be satisfied with our doctors and care. That can be accomplished by giving us the freedom to decide which Tricare medical coverage best suits us and our families and not putting a limit on dates when that switch is available.

From: BB on: July 19, 2017

I switched to Standard after a cancer diagnosis. My PCM, oncologist and surgeon all submitted requests to Tricare seeking approval for a MRI. All were rejected. After appeal, the MRI was approved, I had the test performed the day I received the letter. A week later, I received a letter rescinding the prior approval. I switched to Standard and scheduled appointments with my oncologist, surgeon and MRI within five minutes. (Insert heavenly chorus here) No arguing with Tricare! No back and forth unnecessary appointments with PCM to continue an established treatment plan! Magic!!
In general, the prime process is burdensome. When in crisis, it can be catastrophic. The Army radiologist saw something in my breast, but felt it did not merit further testing. My Army surgeon disagreed and had me sent to a breast center, where it was biopsy proven that I needed a lumpectomy. The Army radiologist is good at his job, but breasts are complicated and best reviewed by radiologists specializing in that tissue. That judgement call could have cost me my life and years of treatment.
Our MTF is extremely busy and has the added burden of perpetually rotating doctors. I was also subsequently diagnosed with a rare type of lymphoma. This would not be something that an Army doc, dealing with a relatively young and healthy population, would ever have seen. (I am young-ish and relatively healthy, so it was even more rare that a person of my demographic would be diagnosed.) My civilian doctor had seen several cases of this and further, I was able to see a specialist in this disease without referral, disapproval, appeal and finally approval.
Waiting for an enrollment date could have made the difference between a simple surgery and months of chemo and radiation, or misdiagnosis. Disease rarely occurs at a convenient time.

From: Alison on: July 19, 2017

Here's a thought. Instead of messing with our insurance provide us with better care. Stop refusing testing. Stop throwing pills at us trying to shut us up. Order testing. Hire more medical professionals. I could go on.

From: Jessica on: July 18, 2017

I love being able to switch between the two. Most of the time prime is a good option. However I prefer to be seen while pregnant with standard care. Faster appointments. It was a much more personable experience with standard. Then once baby is born I switch back to prime. I appreciate the flexability and hope they don't change that.

From: Jessica on: July 18, 2017

One of the best arguments for being able to switch during pregnancy in particular is that mtfs have higher incidences of negative birth outcomes. No ome should literally have to put their amd their child's life on the line because they got pregnant in the wrong month...especially when military families are already so limited on times to potentially conceive due to training and deployment schedules.
Another argument comes from the fact that military Drs also routinely PCS themselves. You could be rolling along, loving your Dr and the care you receive and then boom. One day after the enrollment period ends, you make an appt only to learn that your family Dr has been replaced with someone that has a completely different method of care and bedside manner that does not work for your special needs child. Suffering for 12 months with a carer that does not work for you is not acceptable.
People are comparing this to civilian insurances with their enrollment periods but that is not a reasonable comparison because if you hate your Dr or clinic with a civilian insurance, you can just choose a new one that also takes your insurance. With Tricare Prime, you are assigned a clinic and a PCM and convincing Tricare to let you switch to someone else even at the same clinic can be a challenge or impossible. You can't give people zero choice on who their pcm is AND limit their enrollment options so severely at the same time. It is a recipe for awful care and losing good servicemembers over a policy that cannot possibly save enough money to be worth the risks.
When Drs know that no one can switch from them, they have zero incentive to improve their "product" and consumers lose.

From: Maria on: July 18, 2017

I was very sick with at least 20 horrible symptoms like vertigo and extreme fatigue. My pcm kept telling me I was fine and this continued for almost 2 years. My father ended up paying for an appointment for a doctor off post and she diagnosed me with Hashimoto's thyroiditis, she also ordered an ultrasound of my neck and found 2 nodules and she tested and discovered I have a genetic mutation that interferes with many aspects of my health. I had begged my pcm to refer me to this doctor off post and he refused and told me nothing was wrong with me. I felt like I was dying. If my father hadn't have taken me to the doctor off post, I don't know what would have happened to me. 5 years later I'm still struggling with chronic fatigue and vertigo. I continue to see doctors off post and with the help of family members I pay for those visits out of pocket. It's very frustrating. I feel like the doctors on post are basically pill pushers and they do not listen to their patients concerns. Something has got to change.

From: Jan on: July 18, 2017

If it wasn't for the VA I would still have Lyme disease. I was misdiagnosed for years thru Tricare Prime & now suffer all the after effects of not being treated right away.

From: Evelyn on: July 18, 2017

We have experienced this before . My daughter had huge tonsils and adenoids and the provider at Keesler refused to remove them . He said she should wait until she out grew it as a teen . She had snoring problems also at the time due to the swelling . Since her dad and I are medical we choose to treat her with antihistamines as needed but continued to monitor . Thankfully her provider left Keesler and her new doc was amazing and knew right away she needed them out . Thankfully she survived her bad doc ! Currently we are unable to get treatment appt in reasonable times and have to use ER frequently for ear aches etc . I cannot imagine being stuck in prime with horrible treatment. ER physicians should not be used like they are at times in military installations

From: Gloria Miles on: July 18, 2017

I was in the Navy and obviously couldn't switch from prime to standard until I was a dependent. As soon as I was able to, I switched. I also switched my children to standard. Why? Because the care my children received wasn't exactly up to my standards. I found out my oldest child was allergic to Amoxicillin in the worst way.
He was sick with pneumonia. I called and made an appointment. I was seen right away and my child was prescribed amoxicillin. His fever only got worse and he eventually ended up with hives all over. I made an appointment with the same military doctor. He told me that this was a normal reaction to the medication.
When my child's fever reached 104.7 and would only lower to 103 with both Tylenol and Motrin, I rushed him to the ER. More than just feverish, he was lethargic, which scared me to death. I was informed that he was having an allergic reaction.
I insisted on seeing a different pediatrician when I called to make a different appt. The other military doctor was appalled that the first doctor had dismissed my child's symptoms.
Being standard means that I pay a small fee to see the doctor sometimes. However, I get to shop around and find a doctor I trust. That is worth the small co-pay that is required to be met. If I could shop around for other doctors on Prime, I would have stayed. However, the care I received from some of the military doctors (not all, some were amazing!) made me switch as soon as I could. And now I get to shop for someone I trust with my child's life. That's how it's supposed to work.

From: Holly on: July 18, 2017

I first switched just after we were married in 2005 b/c I was unable to access a timely appt at the MTF.
When I did get an appt, I repeatedly told the nurse practitioner I did not need birth control prescribed, she kept trying to prescribe it. I would repeat that I didn't need it, and she said, so you are trying to conceive? I was concerned that a health professional thought those were the only two options.
Got about 6 letters changing my PCM, went in for a sick appt and was treated like dirt for not knowing who my PCM was. Got a letter two days later changing it again.
Was constantly treated as a second class citizen b/c I was the spouse, not the member.
Was sure I had strep throat. They begrudgingly did a strep test and said they would call me that day. Called the next day, said it was positive and gave me an hour to get to the on base pharmacy b/c it was closing for a team event.
I have never switched back!
Now, I receive allergy immunotherapy shots. After starting the shots over multiple time after moving, I now have an allergist coordinate my care in our home state and send my serum to where we live. That process would be far more difficult, if not impossible if I was on Prime.
This change would be devastating for military families. If the change has to be made, quality and availability of care should absolutely be a qualifying event, as should pregnancy. No one deserves to be treated the way I was treated, and we all deserve to have some say in our providers.

From: Morgan on: July 18, 2017

Similar to Kristin's story, I have a thyroid condition that I'd been working to stabilize for about a year with a specialist prior to getting married to my now husband, who is in the Air Force. I dealt with on base doctors for almost 2 years before making the switch. My issue stemmed from not being seen quickly or communicated with promptly enough when it mattered, meeting new doc after doc thanks to all the PCSing, and watching each one dismiss the symptoms I had because of my undertreated thyroid instead of listening and offering solutions. I switched to standard and saw a regular old PCP who had my thyroid levels and medication stabilized within a matter of months. She also helped me gain control of my symptoms and was available to see me in a reasonable amount of time, unlike MTFs which schedule you up to 3 weeks later, sometimes.

From: Audrey on: July 18, 2017

Personally, I don't think this is fair. I can speak for the base we're stationed at in regards to pediatrics. There has been many, many mommies who have tried to schedule well baby appts and have been unable. At the one month well baby, you schedule the two month (8 week) well baby. They told her there were no appts open until her child would be 14 weeks. That's absolutely unacceptable and denying us the ability to seek care for ourselves and our children when the installation clearly isn't up to standard is unfair. Also, most of us prefer to have our children seen by someone who is a little more qualified than those working on base.

From: Becky on: July 18, 2017

I switched my kids from Prime to Standard several years ago. We were at a large navy hospital and got great care from a phenomenal civilian pediatrician. I switched when she shared that she was leaving practice, and that the hospital hadn't added personnel to cope with two carriers newly moved to the area. That explained why it was so much more difficult to get urgent appointments. I didn't want to continue the hassle of going through them without the benefit of our awesome doctor.

From: Jolene on: July 18, 2017

Written by a spouse with this experience: Overseas medical care should be part of this discussion and not overlooked! The military's goal is not to keep all it's members and their family members in the United States! Tricare is the insurance ALL OVER THE WORLD! If the "Sponsor" and family see military providers (not civilian providers) while in the states, the military has much easier access to your medical history! They want to keep everyone in the family in their system. An overseas assignment will NOT be granted if anything in your medical history shows up that could be cause for the military to make a decision to keep you in the states. Look up EFMP and don't think it can't become an issue for you. Find out what qualifies a family member as EFMP! Once the military determines that one family member is "EFMP", the overseas assignment choices could significantly be slowed to a halt. I do mean halt.